Effect of deep stripping massage alone or with eccentric resistance on hamstring length and strength

ORIGINAL RESEARCH
Effect of deep stripping massage alone or
with eccentric resistance on hamstring
length and strength
Jeffrey Forman, PhD, NCTMB
a,
*, Lisbeth Geertsen, MS, CMT
a
,
Michael E. Rogers, PhD
b
a
De Anza College, Jeffrey Forman/Massage Therapy Program, 21250 Stevens Creek Boulevard,
Cupertino, CA 95014, USA
b
Wichita State University, Department of Human Performance Studies, Wichita KS, USA
Received 6 December 2012; received in revised form 22 March 2013; accepted 8 April 2013
KEYWORDS
Deep stripping
massage strokes;
Hamstring flexibility;
Hamstring strength;
Eccentric resistance
Summary Background: Many studies have evaluated the effects of different interventions on
hamstring length. However, little research has been conducted on the effects of deep stripping
massage strokes (DSMS) alone, or combined with eccentric resistance, on hamstring length and
strength.
Purpose: To determine: 1) if DSMS have an effect on hamstring length and strength and 2) if the
effects on hamstring length and strength are any different when DSMS are combined with
eccentric exercise.
Methods: 89 Community College students and community members between the ages of 18
and 62 volunteered for the study. Of these, 64 demonstrated tight hamstrings on either one
or both sides as defined by supine, passive terminal knee extension of 75and participated
in the study. Strength was assessed by pressing the posterior calcaneus into a strain gauge for
approximately 5 s while seated with the knee flexed to 90. On their tighter side, participants
were administered longitudinal DSMS during 15, 10-s bouts of eccentric resistance with an
elastic resistance band. On their other hamstring, participants were administered 15, 10-s lon-
gitudinal DSMS while lying passive. All massage strokes were performed at a depth of 7 out of
10 on a verbal pressure scale index. Afterwards, the hamstring flexibility and strength tests
were repeated.
Results: Both DSMS with eccentric resistance (10.7%) and DSMS alone (6.3%) resulted in
improved (p<0.01) hamstring flexibility. The improvement following DSMS with eccentric
resistance was greater (p<0.05) than following DSMS alone. Strength was not significantly
affected by either treatment.
* Corresponding author.
E-mail address: [email protected] (J. Forman).
+MODEL
Please cite this article in press as: Forman, J., et al., Effect of deep stripping massage alone or with eccentric resistance on hamstring
length and strength, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.04.005
1360-8592/$ - see front matter ª2013 Published by Elsevier Ltd.
http://dx.doi.org/10.1016/j.jbmt.2013.04.005
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
Journal of Bodywork & Movement Therapies (2013) xx,1e6

Conclusions: These results suggest that DSMS increases hamstring length in less than 3 min but
has no affect on strength. Furthermore, combining DSMS with eccentric resistance produces
more hamstring flexibility gains than DSMS alone and does not affect strength.
ª2013 Published by Elsevier Ltd.
Introduction
Poor flexibility can negatively impact normal biomechanical
balance and function, which can result in impaired
mobility, pain and reduced sports performance. For
example, limited range of motion in the hamstring muscle
group has been associated with postural deviations, low
back problems, impaired athletic performance and greater
risk of injury (Crosman et al., 1984). Athletes participating
in sports that require sprinting and acceleration commonly
experience hamstring injuries. These injuries force many to
miss practice and games and if not adequately treated the
chance for re-injury is high (Brughelli et al., 2009).
Many studies have been performed measuring the effec-
tiveness of different techniques at improving hamstring
length and strength. Techniques such as static stretching,
exercise, heat, massage, proprioceptive neuromuscular
facilitation (PNF) and eccentric training have previously
been shown to improve hamstring flexibility, and although
some studies found PNF superior to other stretching tech-
niques, most comparative analyses were inconclusive as to
which techniques work best (Decoster et al., 2005;Spernoga
et al., 2001;Funk et al., 2001,2003;George et al., 2006).
The utilization of classic massage techniques such as
gliding (effleurage), kneading (petrissage), and friction in
studies by Barlow et al. (2004) and Hopper et al. (2005a,b)
showed non-significant results in terms of improving flexi-
bility of hamstrings. However, Hopper et al. (2005a,b)
employed a technique called Dynamic Soft Tissue Mobi-
lisation (DSTM) in addition to the aforementioned classic
massage techniques, which showed a significant increase in
hamstring length compared to both the control and the
group that received traditional Swedish massage. In the soft
tissue mobilization group the therapist positioned the client
prone and employed deep longitudinal strokes over the
entire hamstring group to isolate adhesions and/or hyper-
tonic tissue. When these areas of myo-fascial restriction
were uncovered the client was turned supine and focused
deep longitudinal stripping strokes were then applied over
these areas of restriction. The knee was first passively
extended, then actively extended and finally eccentrically
contracted against the therapists’ resistance during the
stripping strokes. George et al. (2006) successfully utilized
the Active Release Techniqueto increase hamstring
flexibility. For the intervention participants were placed on
their side with the hip extended and compressive forces
were applied to the dorsal sacral ligaments while the hip
was actively flexed. Participants were then placed in the
prone position where the muscle bellies were treated. The
knee joint was approximated, shortening the hamstrings,
and compressive force was applied and maintained to areas
of restriction in the bellies of the muscles while the subject
actively contracted their antagonistic muscles, lengthening
their hamstrings. The origins of the hamstrings were then
treated using the same principles of joint approximation
and compressive force into the tissue while the antagonist
was contracted. Results showed that hamstring flexibility
on average increased by 8.3 cm.
The results of the Nelson and Bandy (2004) study indi-
cated that even though both static stretching and eccentric
training improved flexibility there was no significant dif-
ference between the two methods. Regardless, Nelson &
Bandy stipulated that a reduction in injuries may be ach-
ieved by implementing an eccentric training program that
takes a muscle through a full range of motion as this pro-
vides a more functional option for flexibility training.
Ferreira (2007) reported that their comparison between
static stretching and eccentric training resulted in the same
non-significant gains in hamstring flexibility. In agreement
with Nelson & Bandy they opined that eccentric training
was a better strategy to use for training because, in addi-
tion to increasing flexibility, it increases strength and can
help protect against injuries.
Brughelli et al. (2009) argued that, since muscle has an
optimum length for producing peak tension, hamstring in-
juries can be reduced if this optimum length is increased
via training. They concluded that eccentric exercise is the
only form of training that has consistently been shown to
increase the optimum length of tension development and
emphasized the importance of using functional movements
with eccentric muscle contraction to rehabilitate hamstring
muscle injuries. Aquino et al. (2010) studied individuals
with tight hamstrings and compared the effect of
strengthening the hamstrings in a lengthened position
versus stretching. They reported no significant change in
flexibility for the stretching and strength training groups,
but the strengthening in the lengthened position group did
demonstrate changed peak torque angles in the direction of
knee extension. The authors suggested that strength
training in the elongated position most likely induces
structural adaptations in shortened muscles, which may
help prevent musculoskeletal injuries.
Finally, in a pilot study by Forman et al. (2011) the ef-
fects of a warm-up versus deep stripping massage strokes
DSMS combined with eccentric resistance on hamstring
length were examined. Participants were taken through a
pretest terminal hamstring length goniometer measure-
ment, which was followed by a five-minute warm-up on an
exercise cycle with zero resistance. After the warm-up,
another hamstring length measurement was recorded.
Then a series of fifteen ten-second bouts of hamstring
eccentric resistance exercises were combined with DSMS
before a final goniometer measurement of hamstring length
was completed. They found that both warm-up and
combining eccentric resistance with deep stripping mas-
sage increase hamstring length significantly, however the
2 J. Forman et al.
+MODEL
Please cite this article in press as: Forman, J., et al., Effect of deep stripping massage alone or with eccentric resistance on hamstring
length and strength, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.04.005

combination of eccentric exercise with DSMS was three
times more effective than the five-minute warm-up.
Our analysis of research has focused on techniques that
have demonstrated the potential to increase muscle length
and strength. Other researchers have suggested that
eccentric training is an effective tool for increasing muscle
length and strength and recommended it for preventing
injuries (Nelson and Bandy, 2004;Ferreira, 2007). A great
deal of research on eccentric training has been conducted,
however certain avenues have not yet been investigated.
There is a paucity of research on the effects of DSMS and
minimal investigation has been conducted on the effects of
combining DSMS with eccentric resistance. Therefore, this
study seeks to fill the void in the existing research by
investigating the effects that DSMS alone and combining
DSMS with eccentric resistance have on hamstring length
and strength.
Methods
Subjects
Participants between the ages 18e62 years (NZ89) were
recruited through advertisements in the school newspaper,
by informing all coaches of the sports teams, and by con-
venience. Of these, 64 participants (Age: 31.4 12.1;
29.7% women; 70.3% men) qualified with either one or both
hamstrings tight (85.9% right-side dominant; 14.1% left-side
dominant) to match the criteria and with no history of
knee, thigh, hip or lower back problems for one year before
the study.
The Institutional Review Board of Wichita State Univer-
sity reviewed and approved the project according to the
Federal Policy for the Protection of Human Subjects. All
participants received written and oral instructions for the
study and each gave their written informed consent prior to
participation.
Community College adult students between the ages of
18 and 62 participated in this study. Individuals were
allowed to participate if they had tight hamstrings, as
demonstrated by a 15or more knee extension deficit
measured supine with the hip flexed to 90and the ankle
relaxed and no history of knee, thigh, hip or lower back
problems for 1 year before the study. Bilateral hamstring
pretest measurements were taken to record pre-
intervention hamstring lengths and strength. Subjects
were positioned supine on a massage table and hips were
secured with a padded belt placed over both anterior su-
perior iliac spines to eliminate pelvic rotation before
hamstring measurements were taken. Hamstring flexibility
measurements were recorded with a Hoggan Health In-
dustries (West Jordan, UT) microFET3 digital muscle tester/
inclinometer set to inclinometer. Before every measure-
ment the machine was calibrated to zero using a pre-
leveled surface. The subject was placed into 90of hip
flexion and while maintaining the 90of hip flexion they
were passively moved into their terminal hamstring length
by a researcher extending the knee. When the researcher
felt end-feel and the subject verbally agreed that terminal
length was achieved another member of the research team
placed the microFET3 on the anterior tibia four fingers
inferior to the anterior fold of the ankle and recorded the
measurement.
After the length of each hamstring was recorded, the
microFET3 was set to muscle testing on the high threshold
setting to measure and record the strength of each
hamstring. To measure hamstring strength the participant
was seated on the edge of a desk with the knee of the leg
being measured flexed to approximately 90. The micro-
FET3 was attached to the side of the desk with Velcro,
posterior and slightly superior to the center of the subjects’
calcaneus. After the participant was directed to fold their
arms across their abdomen members of the research sta-
bilized both shoulders and the contralateral leg. The
participant was then instructed to maximally contract their
hamstring pushing against the machine with their calcaneus
for approximately five seconds. For consistency, a metro-
nome was used while the subject was instructed to “con-
tract, 2, 3, 4 and stop”. After the pretests were completed
the interventions were administered to all participants.
Interventions
Advanced massage therapy students of De Anza College
performed the massage strokes and procedures for both
interventions. These soon-to-graduate students received
advanced training to become part of the research team.
Every team member was familiar and confident with the
different tasks required for each intervention. One massage
therapist would complete both deep stripping massage in-
terventions on each participant. However, between sub-
jects the massage therapists would switch roles so that
fatigue of the therapist would not affect results.
For Intervention A, the participants were positioned
prone on a massage table and a researcher placed a Velcro
extremity strap that had a green Thera-Band elastic resis-
tance band (Hygenic, Akron, OH) attached to it around the
participant’s ankle (Fig. 1).
The leg chosen for deep stripping combined with eccen-
tric contraction was the leg with the tighter hamstring. If
equally tight, the dominant leg was chosen. The free end of
the resistance band was attached to the underside of the
massage table and adjusted so that there was no slack in it
to provide eccentric resistance throughout the full range of
motion during the intervention. A few drops of Prossage oil
were then gently spread on the participants’ skin. A
metronome set to one beat per second was turned on to
help maintain consistent timing. The participant was then
passively moved into knee flexion beyond 90, so that they
experienced zero concentric resistance. After releasing the
ankle the participant was instructed to engage their
hamstring muscles countering the resistance of the resis-
tance band so that it took a full 10-s count for the leg to be
fully extended. As the participant slowly lowered their leg
under resistance, a massage therapist concurrently per-
formed a series of deep longitudinal stripping massage
strokes (7 out of 10 on the verbal pressure scale) up the
participants’ hamstring muscles from the insertion points to
the ischial tuberosity (Fig. 2).
The massage therapists would discuss the verbal pres-
sure scale with the participant before the interventions
began. During the procedures the therapist would ask the
Deep stripping massage and/or eccentric resistance effect on hamstrings 3
+MODEL
Please cite this article in press as: Forman, J., et al., Effect of deep stripping massage alone or with eccentric resistance on hamstring
length and strength, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.04.005

participant for feedback on the pressure and adjust the
amount of force applied during the strokes to what the
participant considered to be a seven. Everyone has a
different level of force tolerance and the intention was to
apply firm strokes without unnecessary pain. This subjec-
tive feedback from the participants allowed the massage
therapists to work at an appropriate level of force for each
individual. These deep-stripping strokes were first applied
to the lateral aspect of the hamstrings, then the center and
finally the medial aspect. A total of fifteen deep stripping
massage strokes were applied to each hamstring group. The
longitudinal stripping massage strokes were applied with
the flats of the knuckles of one hand as the therapist
reinforced their wrist by grasping it with their other hand.
The therapist held a green Hand Exerciser (Hygenic, Akron,
OH) ball as a shock absorber in the hand performing the
strokes (Fig. 3). Intervention B was administered immedi-
ately following the completion of intervention A.
For intervention B, which was performed on the less
tight hamstring (and if equally tight the non-dominant leg),
fifteen deep longitudinal stripping massage strokes were
applied in exactly the same manner. However, the partic-
ipant was passive and did not perform any eccentric con-
tractions during the treatment.
Immediately after the massage strokes for intervention
B were completed the participant’s hamstring length and
the strength of both legs were measured with the afore-
mentioned pretest protocols.
Statistical analysis
Data analysis was completed using the statistical software
program SPSS for Windows V.18.0 (SPSS Inc., Chicago, IL).
Data were screened for outliers, and assumptions of
normality and homoscedasticity. To reduce the potential
influence of outliers on the statistical analysis, box-and-
whiskers plots were used to identify outliers, which were
subsequently eliminated prior to analysis. Each variable
was examined for normality using the Kolomogor-
oveSmirnov test. Assumptions of homogeneity of variance
and sphericity were evaluated. Baseline group mean com-
parisons were performed using a one-way ANOVA. Repeated
measures ANOVA procedures were conducted using the raw
values to evaluate the effects of the interventions. Percent
change scores were also calculated from the difference in
scores. A probability value of less than 0.05 was considered
statistically significant.
Results
The qualifying participants (nZ64) completed both in-
terventions. Groups were divided into DSMS with eccentric
resistance and DSMS alone. Groups were similar at baseline
Figure 1 Velcro extremity strap attached to the ankle with
an elastic resistance band attached to the strap and the table.
Figure 2 Deep stripping massage stroke combined with
eccentric resistance.
Figure 3 Reinforcing the wrist and using the hand exercise
ball as a shock absorber.
4 J. Forman et al.
+MODEL
Please cite this article in press as: Forman, J., et al., Effect of deep stripping massage alone or with eccentric resistance on hamstring
length and strength, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.04.005

for both flexibility and strength measures. For DSMS with
eccentric resistance there was a 10.7% improvement
(p<0.01) in flexibility following intervention. For the
group receiving only DSMS, there was a 6.3% improvement
(p<0.01) in flexibility. A comparison between groups found
that the improvement in flexibility following the combina-
tion of stripping strokes and eccentric resistance was
significantly greater (p<0.01) than following stripping
strokes alone (Table 1).
There was a non-significant 1.1% increase (p>0.05) in
strength following the combination of stripping strokes and
eccentric resistance. There was also a non-significant 1.8%
decrease (p>0.05) in strength with massage only (Table 2)
Table 3.
Discussion
This study attempted to determine the effects of DSMS
combined with eccentric resistance (intervention A) versus
DSMS alone (intervention B). We were able to reject the
null hypothesis regarding flexibility as we saw a significant
difference in flexibility comparing the results from inter-
vention A and B. Although both interventions were effec-
tive at increasing flexibility significantly, the leg that was
submitted to DSMS combined with eccentric resistance
showed significantly greater gains than the leg where only
DSMS were applied. The superiority of combining DSMS with
eccentric exercise was also seen in a previous pilot study
conducted by Forman et al. (2011).
The reasoning behind the greater gains in flexibility
when adding eccentric resistance to DSMS may be found in
the rapid training effect, which has been explored in a few
studies on eccentric exercises by Lynn and Morgan (1994)
and Lynn et al. (1998). The training effect refers to
improvement in functional ability and strength due to
changes in the muscular, cardiovascular, and neurological
systems, and in their study of rats Lynn and Morgan (1994,
1998) found that the number of connected sarcomeres in
the vastus intermedius muscle fiber increased during
decline running. This is possibly the same phenomenon
Simons et al. (1999) are referring to when suggesting that
lengthening contractions may equalize sarcomere length.
In terms of strength there were no significant increases
following any of the interventions. Wiktorsson-Moller et al.
(1983) noted the same lack of effect of massage on
strength. If rapid training effect causes adaptations in the
muscular and neuromuscular systems, and thus has an ef-
fect on flexibility it cannot explain why similar adaptations
in strength did not take place in the current study. How-
ever, a study by Raastad and Hallen (2000) found that
muscles exposed to eccentric training with maximal
contraction were 12e14% weaker 5e20 min after exercise.
Raastad and Hallen speculated whether the causes of fa-
tigue were from the central nervous system in the form of
reduced motor drive or from the peripheral nervous system
and thus within the muscle. They concluded that since
reduced neural activation seem to recover within five mi-
nutes, the prolonged fatigue had to come from within
the muscle itself possibly due to reduced Ca
þþ
release from
the sarcoplasmic reticulum caused by changes in the
excitation-contraction coupling.
In the current study, the participants had less than five
minutes to recover from intervention to post test, and thus
their hamstrings could still be fatigued from the eccentric
loading and massage combination. Given adequate time to
recover the potential for significant strength gains would
possibly increase.
Although the current study showed significantly better
results combining DSMS with eccentric resistance than by
utilizing only DSMS, the technique will need to be
researched further in order to fully determine its benefits
relative to other techniques aimed at improving flexibility,
e.g., ART and PNF. Additionally, further study is needed to
determine how long flexibility is enhanced following DSMS
combined with eccentric resistance. This is a shortcoming
of most research on soft tissue techniques, and thus there is
limited scientific evidence as to whether improvements are
transitory or have a lasting effect. Finally, training
studies utilizing these techniques are warranted to deter-
mine the effects of repeating these measures on flexibility
and strength over time. This will be of importance to
Table 1 Means & standard deviations for flexibility measures (degrees).
NMean Std. deviation Range Minimum Maximum
Pre flexibility: stripping þeccentric 64 64.4 8.2 33 42 75
Post flexibility: stripping þeccentric *^64 71.3 9.3 40 48 88
Pre flexibility: stripping alone 64 69.5 8.6 44 45 89
Post flexibility: stripping alone * 64 73.9 9.0 38 49 87
* Within group comparison: p0.01;^Between group comparison: p0.01.
Table 2 Means and Standard Deviations for Strength Measures (kg).
NMean Std. deviation Range Minimum Maximum
Pre strength: stripping þeccentric 64 6.5 3.3 15.1 1.6 16.7
Post strength estripping þeccentric 64 6.6 3.8 14.8 2.1 16.8
Pre strength estripping alone 64 6.7 3.4 13.2 1.4 14.6
Post strength estripping alone 64 6.6 3.9 15.9 1.6 17.5
Deep stripping massage and/or eccentric resistance effect on hamstrings 5
+MODEL
Please cite this article in press as: Forman, J., et al., Effect of deep stripping massage alone or with eccentric resistance on hamstring
length and strength, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.04.005